Diabetic Foot Syndrome

Diabetic foot syndrome submitted 26.06.2025 accepted 25.07.2025 German Diabetes Association : Clinical Practice Guidelines This is a translation of the DDG clinical practice guideline published in Diabetol Stoffwechs 2025; 20: S347–S359. doi: 10.1055/a-2592-8610 Notice of update The DDG clinical practice guidelines are updated regularly during the second half of the calendar year. Please ensure that you read and cite the respective current version. UPDATES TO CONTENT AND DIFFERENT RECOMMENDATIONS COMPARED TO THE PREVIOUS YEAR’S VERSION Change: In [ Table 7 ], forms have been adapted. Punctuation marks have been added for better comprehensibility especially for VIIb, VIIc and VIId. Definition Diabetic foot syndrome is understood to be all pathological changes affecting the foot of a person with diabetes mellitus. These include pre-ulcerative lesions such as abnormal corns/callouses. Ulcers or necroses usually develop as a result of repetitive trauma with limited sensation of pressure and pain in the context of diabetic polyneuropathy (e.g., in the form of high pressure and shear stress, especially in foot and toe deformities). In Germany, more than 50% of all cases are characterized by a relevant peripheral arterial occlusive disease (PAOD), whose symptoms (claudication and pain at rest) are often masked by polyneuropathy. Epidemiology The most significant manifestations of diabetic foot problems are ulcerations, deforming changes of the foot skeleton (Charcot foot) and amputations. The annual rate of new cases of acute diabetic foot syndrome (DFS) is about 2%. The manifestation probability of DFS over the entire lifetime of a person with diabetes is 19–34%. For many years, Germany was at the top of the European amputation rates, but a recent large nationwide study showed a decrease in major and minor amputations in the diabetic population compared to the non-diabetic population. The result of this study thus confirms a positive trend that has already been observed in smaller and regional studies in recent years.[ 1​ ] Even today, 65–70% of all amputations are performed on patients with diabetes mellitus. Risk factors Foot lesions or acquired foot deformities in people with diabetes are the result of multifactorial events with the following major causal factors: Neuropathy (sensory, motor, and autonomous) PAOD Limited joint mobility Pressure deformities (e. g. due to unsuitable footwear, foot and/or toe deformities, and obesity) Corn/callus formation as a sign of incorrect pressure distribution Biopsychosocial factors (e. g. depression, neglect, beliefs about illness, and lack of social support) Examination All people with diabetes should have their feet and shoes examined regularly ([ Table 1 ]). Table 1 Control intervals of foot examinations depending on the individual risk status Risk category Risk profile Examination 0 No peripheral neuropathy 1× yearly 1 Peripheral neuropathy 1× every 6 months 2 Peripheral neuropathy with PAOD and/or foot deformity Every 3–6 months (specialist) 3 Peripheral neuropathy and ulcer or amputation in the medical history Every 1–3 months (specialist) The following points are integral to each foot examination as part of the controls in the corresponding disease management programs for type 1 and type 2 diabetes and must include at least the following: Specific anamnesis (the presence of burning or stabbing pain, paraesthesia, numbness, and the absence of any sensation); loss of protective sensation (LOPS). Bilateral foot examination: skin status (integrity, turgor, perspiration, and calluses), muscles, deformities, mobility, skin temperature, etc. and Checking of pressure sensation with a 10 g monofilament and/or testing of vibration sensation with the Rydell-Seiffer tuning fork, palpation of foot pulses (posterior tibial artery and dorsalis pedis artery). Pressure sensation The filament is applied with light pressure so that it bends slightly, creating a pressure of 10 g. If this pressure is no longer perceived by the patient, the sensation of pressure is already considerably reduced, and the natural protective function is therefore no longer reliable. Scarred or calloused skin is unsuitable for testing. Foot pulses Finding the foot pulses by touch depends on the room temperature. In the case of non-palpable pulses on the feet, the pulses of the popliteal and femoral arteries should be examined. Palpable foot pulses do not rule out PAOD! Further examinations are recommended (see the evidence-based guideline “Diagnosis, therapy, follow-up and prevention of diabetic foot syndrome” of the DDG, www.AWMF.de ). Measurement of the arterial occlusion pressure over the dorsalis pedis artery and the posterior tibial artery, Determination of the ankle-brachial index (ABI) and Better: Determination of the toe-brachial index (TBI). Peripheral arterial occlusive disease The usual symptoms of PAOD (intermittent claudication, pain at rest, pathological skin temperature and colour) are often absent in patients with concomitant neuropathy. The scope of the risk is therefore underestimated. The ABI as a screening method is of limited use in the presence of an autonomic neuropathy with associated media sclerosis and the resulting incompressibility of the arteries of the lower leg and foot. The most reliable combination of findings for the exclusion of a relevant PAOD in DFS is a TBI of ≥0.75 and the detection of triphasic Doppler signals.[ 2​ ] Further examination procedures include colour-coded duplex subtraction angiography, magnetic resonance imaging (MRI) of the pelvic and leg vessels and, if necessary, digital subtraction angiography (DSA) in readiness for intervention. Before and after angiography, proper hydration must be ensured to avoid contrast agent nephropathy. Where renal insufficiency is present, MRI should only be performed after weighing the benefits and potential risk (low!) of gadolinium-induced systemic fibrosis on a case-by-case basis. In such cases, DSA using CO 2 for contrast can be performed. Computer tomographic angiography is not suitable for people with diabetes due to the high contrast medium requirement and the low separation precision between vascular lumen and calcified plaques, especially in the arteries of the lower leg. All national/international guidelines clearly stipulate that this reduced blood flow must be corrected if vascular involvement occurs, ideally by means of minimally invasive percutaneous transluminal angioplasty (PTA) or vascular surgery. If both are no longer possible (non-reconstructable extremity and no-option), many alternative methods for the improvement of arterial perfusion are offered and often applied without any proof of effectiveness.[ 3​ ] Good clinical practice in diabetic foot syndrome always means following interdisciplinary and multi-professional treatment paths. These include, at minimum, the coordinated combination of wound debridement, infection treatment, stage-appropriate wound management, targeted pressure relief, and arterial revascularisation and surgical measures. If a patient is diagnosed with a lesion as part of diabetic foot syndrome, it should be classified according to the extent of tissue damage and the presence of infection and/or ischaemia (Wagner classification, combined Wagner–Armstrong classification; [ Figs. 1 ] , [ 2 ] and [ Tables 2 ] , [ 3 ]). The current International Working Group on the Diabetic Foot (IWGDF) guideline includes an entire section on the classification of diabetic foot ulcers.[ 4​ ] The implementation of the recommendations formulated in the report for Germany is currently being discussed in the committees. Fig. 1 Foot documentation sheet—page 1. Source: Working Group on the Diabetic Foot of the DDG. Fig. 2 Foot documentation sheet—page 2. Source: Working Group on the Diabetic Foot of the DDG. Table 2 Classification according to Wagner Wagner grade Extent Measure 0 No ulcer but possible foot deformation or cellulitis Regular check-up of the feet 1 Superficial ulcer The focus is on pressure relief and local wound treatment 2 Deep ulcer extending into joint capsule, tendon, or capsule The focus is on pressure relief and local wound treatment 3 Deep ulcer with abscess, osteomyelitis, and infection of joint capsule Infection control; smaller osteomyelitic foci usually heal with systemic antibiotic treatment and consistent pressure relief, larger foci usually have to be resected; X-ray control lags somewhat behind the actual condition of the bone; if the clinical findings are improved, the continuation of the antibiotic treatment can be made additionally dependent on signs of inflammation in the blood; normally, even small cases require antibiotic treatment of 6 and more weeks 4 Limited necrosis of forefoot or heel area Treatment is mainly concerned with keeping the level of amputation as distal as possible and preventing ascending infection; in the case of PAOD, angiography should be performed before each amputation 5 Necrosis of the complete foot Treatment is mainly concerned with keeping the level of amputation as distal as possible and preventing ascending infection; in the case of PAOD, angiography should be performed before each amputation PAOD, peripheral arterial occlusive disease. Table 3 Wagner–Armstrong classification. Possibilities for describing diabetic foot syndrome using the combined Wagner–Armstrong classification Wagner grade 0 1 2 3 4 5 Armstrong stage A Pre- or post-ulcerous foot Superficial wound Wound to the level of tendons or capsules Wound to the level of bones and joints Necrosis of parts of the foot Necrosis of the complete foot B With infection With infection With infection With infection With infection With infection C With ischaemia With ischaemia With ischaemia With ischaemia With ischaemia With ischaemia D With infection and ischaemia With infection and ischaemia With infection and ischaemia With infection and ischaemia With infection and ischaemia With infection and ischaemia Treatment Only a multidisciplinary, multi-professional and trans-sectoral approach to the treatment of foot ulcers can significantly reduce the frequency of amputations. Essential components of the treatment of diabetic foot ulcers are: Metabolic optimisation and treatment of internal underlying diseases, Infection control, Debridement of avital tissue parts, Effective pressure relief, Stage-appropriate local wound treatment, Therapy of vascular diseases, Surgical correction of foot deformities and/or misalignments and Patient training. Metabolic optimisation and treatment of internal underlying diseases Metabolic optimisation is indispensable for optimising immune competence, improving hemorheology and thus microcirculation, and preventing progressive pathological glycation. Concomitant diseases, which impair Immune competence, Hemoperfusion or Tissue oxidation should be treated appropriately. Infection The diagnosis of infection is made clinically in the presence of systemic or local indications. The extent of infection in diabetic foot syndrome is classified as mild, moderate and severe, and life-threatening or non-life-threatening ([ Table 4 ]). Inpatient admission is indicated in the case of severe (and possibly moderate) infection (measures: adequate fluid intake, metabolic control, calculated, if possible targeted antibiotic therapy, drainage, complete pressure relief, and further surgical measures, if necessary). Infection with multi-resistant bacteria worsens the prognosis. It is essential to prevent infections from colonisation and contamination. To avoid resistance development, treatment should be carried out according to the criteria of antibiotic stewardship: the correct indication, the correct drug (targeted culture-controlled administration), the correct form of application, and the correct dose. In patients with chronic recurring foot lesions or recurring antibiotic treatment, a patient antibiotic booklet is recommended.[ 2​ ] Table 4 Clinical classification of foot infections. Data according to ref.[ 5​ ] [ ​6​ ] Clinical manifestation of infection Severity of infection PEDIS classification Wound without suppuration or signs of inflammation Not infected 1 Presence of two or more signs of inflammation (suppuration, redness, [pressure] pain, and warmth or sclerosis), but each sign of inflammation ≤2 cm around the ulcer; infection is limited to the skin or superficial subcutaneous tissue; no other local or systemic disease 2 Infection in a patient is and but or more of the following of inflammation which cm around the the superficial in and to tendon, joint or 3 Infection with Infection in a patient with systemic signs of infection or (e. severe or 4 Infection with and The presence of ischaemia the of the infection of but reduce the clinical signs of Wound Wound is for the of other treatment measures. (e.g., using of in the wound of the wound if Before is adequate arterial perfusion should be is due to the are usually not due to the of wound and tissue by in medical Pressure relief In it must be to all and that pressure and shear relief is of the this is a recurring due to the to the current recommendations of the the following for pressure relief should be 2​ ] The means of for ulcer are or lower leg not If are for the from 1 or if are not by the patient, a is as a The patient should always be about the of the If other for relief are not not but always with suitable For ulcerations, etc. For ulcers on the of the with toe deformity the of the digital is surgical to pressure (e.g., and For pressure relief, of is wound treatment For the of wound treatment and temperature The wound should be at each The of in an individual case should be on the criteria of wound presence or absence of signs of and 2​ ] [ ] [ ] [ ] [ ] [ ] The current guideline of the clearly that for most wound is no of that it is not the wound but the of the wound by management and as a that to the Therapy of vascular diseases In the presence of PAOD, the for revascularisation procedures or must be made if the foot lesions do not heal or if is a risk of blood wound is not to be In the of arterial revascularisation must be if a foot lesion not a 4 weeks wound 2​ ] and each use depends on the distribution of PAOD, the of the vascular and the and of the as as the presence of a suitable leg as the In most cases, should be that both revascularisation procedures are ] patients with the of ulcer prevention be a to reduce both amputations and the ulcer for is If amputation is necessary, the extent of the amputation should be as small as possible in to and the possible to each a vascular diagnosis must be and the of revascularisation must be A major amputation the as a treatment is of the second before amputation for DFS has been in the on the second With the of the Working Group on the Diabetic Foot in the DDG, of the essential of the and with the to about the to a second medical the of the of the All in this such as vascular trauma and and are to foot and in interdisciplinary should be in the second before amputation in patients with diabetic foot syndrome at an ] is made to foot treatment of the Foot Working Group in the DDG for for and Diabetic and Clinical is associated with the of or joints and/or bones by stage of and [ Tables 5 ] and [ 6 ]). In to the neuropathy of are the of diagnosis in the acute of the disease foot) is for the if possible before and deformities have This stage of is and by an in temperature with to the the with the temperature on the foot as the of the on the as as formation and/or These symptoms should always be an to a diagnosis of are must Table 5 of diabetic according to Clinical foot and X-ray be and joint changes and Foot foot due to and joint foot lesion Table 6 of according to and joints and joint joints If possible and without damage to the should be performed with on the foot and joint by an of the entire foot. X-ray of the other foot should be for in the of the disease often do not any pathological changes or an MRI is indicated if is and the X-ray is If an MRI be a should be as an are not suitable for or out Therapy With diagnosis and therapy, the is Further and the of or joint can usually be by the foot and lower leg in a and using or lower leg not as any of can both to and to for a surgical that be in the in the treatment of or the of an of the of the foot and entire lower leg. The use of is in small as is often for patients after and is not possible due to polyneuropathy. It is to to proper and for the other foot as is a relevant risk for the of a on the other as The treatment of is at the of the is positive that of the foot can be after the of the level and can from surgical and in the case of deformities with a high risk of with an in especially in the or in the case of It is of the is and/or an ulcer is The surgical treatment should be at an stage in an interdisciplinary into the as can to an severe and deformity and thus more and the Specific and are not The of and D can be during the The clinical signs of inflammation are for the of to during the of the The of on MRI can be for it be after clinical Even a moderate in skin temperature over the area by can for if after or with the formation of of of a has been and from the the patient should be with or with which are to the of the feet and and the possible to prevent of the If no surgical correction can or should be carried out after individual more severe deformities and/or joint (e.g., should be ] of as as the prevention of recurring events and amputations are of of patients foot lesion or clinical examination of and Regular examination of feet and the of skin temperature in patients with footwear, if necessary, and treatment of other pathological changes in the treatment, of all and The most is the of feet and as as to prevent acute events from the loss of protective as part of neuropathy (LOPS). The individual risk profile of the patient must be into during the examination intervals ([ Table 1 ]). The foot is not only by an ulcer or pre-ulcerative are risk that can be before an and by proper measures. factors a major in the of diabetic foot as a result of to pressure and shear during The most of lesions is is unsuitable or not Therapy and/or prevention include foot such as the of the in the case of forefoot pressure or of tendons as with (see of The of amputations is significantly reduced by by a of vascular and diabetes and In with the recommendations of the of the patient to an interdisciplinary and multi-professional foot treatment is therefore ). For Germany, the DDG Foot Working Group has and that the of and, at the patients require suitable for both and The of for patients with diabetes are more on and suitable with even pressure distribution than on and correction of The and especially the should be for and, if necessary, The to pressure their over prevention the of ulcers can be by for their by means of pressure in the A classification of the stage-appropriate of is at ([ Table 7 ]). of the as as for the of for people with diabetes was published by the Working Group by ] Table 7 of and risk for diabetic foot syndrome and associated Data according to [ ] and [ Fig. ] for the of for diabetic foot syndrome Risk 0 Diabetes without and shoes suitable for feet in with foot deformation risk of of due to Diabetes with loss of due to PAOD risk of to the feet, due to unsuitable shoes suitable for DFS with Diabetes with loss of due to and/or PAOD with the following 1. ulcers 2. pre-ulcerative changes renal insufficiency 1. in the case of toe room in the in the case of or for DFS with 2. after ulcer risk of ulcer compared to grade for DFS with with as as with deformities or should not be with shoes (e.g., for shoes for with joint and/or In shoes in the case of in the area or in the case of shoes for If necessary, shoes for DFS with possible for feet with in with foot section amputation possible as internal amputation as in and as lesions can to use their current if the is proper shoes in with the wound pressure on the ulcer shoes without lesion of the with The treatment is the of and tibial are to can only be for feet VIIc heel In case of or infection and PAOD must be infection or moderate PAOD In the presence of infected ulcerations, PAOD or severe should be with as a second or shoes with pressure relief as a heel lesion risk of lower leg amputation heel relief with and of heel relief do not In the presence of infected ulcerations, PAOD or severe relief should be with diabetic foot peripheral arterial occlusive diabetic foot for [ Table 7 ] [ ] DFS for the in and No over foot No toe with an on the with pressure in the area by and of A medical of the with the patient is always The of the is carried out by the of the Fig. 3 for the of for diabetic foot Source: Working Group on the Diabetic Foot of the DDG. PAOD, peripheral arterial occlusive risk classification; loss of protective diabetic foot over the to the patient, the function must be for and and, if necessary, by the components the proper it for and it to the on the the proper function ensured in of the foot and for the criteria for for DFS The protective be in the as or The documentation of targeted local pressure relief a is only possible with the of is to methods for the documentation of of pressure due to For the correction or of a of foot deformity by means of a must be according to a or The current of only for In individual cases, a from the is possible with more or as the medical The criteria for a level of must be and the corresponding must be on the medical A major amputation joint or joint with of the of the function of or both of 2 insufficiency with or In the case of an acute lesion or acute relief with an or is only in In the case of an pressure relief and pressure are of for is on For examinations are at least every 3 months from THE of the evidence-based guidelines International Working Group on the Diabetic Foot Guidelines International Working Group on the Diabetic Foot Guidelines German translation Examination form of the Working Group on the Diabetic Foot for the treatment of diabetic foot syndrome to other that about the diabetic foot syndrome on diabetes of the recommendations for targeted antibiotic on 2 Diabetes www.AWMF.de PAOD of the German of for people at risk of parts of a foot or even a leg due to diabetic foot syndrome published All Germany